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  • Update in global mental health: Lessons from Ukraine by Dr Julia Rozanova, Programme Leader of the MSc in Global Mental Health, King’s College London; Alexandra Deac, KCL Mental Health Researcher; and Prof Dennis Ougrin, CAMHS Consultant/Co-lead of Ukrainian Medical Association of the UK (UMAUK)

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So I see the next session which is updates in global mental health lessons from and we're very lucky to have with us three speakers. The first is Doctor Julia Rosano. Doctor Rosano is a lecturer in global mental Health at King's College London and CODS the Masters in Global Mental Health. The research sits at the intersection of HIV, addiction and aging. Since 2014. She has worked in the Eastern Europe and Central Asian region, developing, developing and HIV prevention and treatment interventions in the community as well as in prison settings. Since beginning of the Russian invasion in Ukraine, the research has focused on how HIV and addiction treatment systems, humanity and what any patients itself and strategies may have in the short and long term users and health care workers. Um Alexander Diak is a postgraduate researcher at King's College, London, Yale School of Medicine and the University of East London to cross health systems, strengthening projects of global mental health. The research endeavors include HIV and addiction system, adaptations and health seeking behaviors and among the groups collaborating closely, we've got to do that. She co-founded the Global Mental Health Humanitarian Coalition, bringing together diverse stakeholders in the humanitarian field to research and practice. We also have with us, Professor Dennis, professor is an NHS consultant, child and adolescent psychiatrist at South London and the NHS Foundation Trust and co-leader of Ukraine Medical Association of the UK. He's also like the Masters in Child and Adolescent Health at college and act as chief investigator of Major NIH R Medical Research Council and funded studies in the field of self harm and intensive care services. It needs a program of global mental health studies aimed at developing community mental health services in Ukraine and other low and middle income countries like the please. Can you hear me? Hi? Ok, perfect. Thank you so much. Um Thank you so much for this generous introduction and for having me. Um I'm going to speak with you about some lessons that we learned as we were um doing some work in your brain. And uh the disclaimer is that I'm not a specialist in emergency medicine or anything to do with rises or disasters. So that wasn't done by choice but because I was working in Ukraine when a series of disasters started to happen, um I had to engage with that and so I have to learn a lot of things uh about crisis and how you do the work during crisis just because the crisis happened around me. But I believe that this is also useful for the rest of the world. And I will tell you why here in this story. So this um presentation is um sort of um a synthesis of our collective know how of what we learned about doing mental health research during crisis. So um our group, because people who are interested in theory, and we have been trying to think about like what a crisis means as a disruption to the normal state of affairs. And then of course, that raises the question of what is normal. So what is the state of school? Um So if we go back to the theory where, you know, there is a stable reproduction of social institutions that is by and large, you know, uh something that is normal. However, a crisis means that we don't know if social institutions such as medical system or educational system or anything else, family will continue to exist as we know it. And that can um happen radically and dramatically in a very quick um period or, you know, it could be an crisis or it can be chronic crisis where things um just sort of get shaken up periodically and you never know which food you stand up, you know, on. So then there usually is some kind of period of stabilization and then people adapt and uh systems adapt um to that mode of being shaken up and then it can be growth and the um posttraumatic growth can happen to people that can also what happened to societies. So all of that is um somewhat simultaneous. It doesn't always go in that nice order as the scheme shows. And it can also kind of like go in there, you know, both like um work wise and counter work wise. And so that makes it very messy and very complicated. And uh the questions are, is the price is a level with uh 100% bad only because even in the worst disasters, people find some meaning and they find it the way those who survive obviously to, to do some rules to do some exploration of what other learnings from. That doesn't mean that, you know, it's a good thing. So here we are trying not to say like how we prevent crisis, which is a very important question obviously. But you know, that's not what we can do, but what we can learn from that and how we can function during the crisis and also in the context of other crisis. And so that kind of brings me to why we thought that um what we were absorbing in the brain where we've been working over time is interesting, important, not just because Ukraine is so unique, which it is, but also because crisis are the new normal in our life. So, um you know, it has no longer that exotic feeling of some are far away, you know, the Ukraine or, or you know, you name it any kind of far away land. But when COVID struck, crisis was brought home. And so, you know that it was a big disruption and crisis, natural or manmade or both find you where you are. So you don't have to go somewhere else to encounter that. And during that time, uh it's an amazing opportunity for building the evidence space for patient treatment also to look at the system resilience. So, you know, um what struck me in those previous talks was that so few people were able to hold the shock in those contexts. But you know, when is it no longer possible? So if you take one anesthesiologist out of the picture, then the two remaining one can still function. If you take the 2nd 11 is still able to bear the burden. But if you take the last person standing, what happens, right. So where is that end point beyond which system will simply collapse like the co the House of Cards. And so to live for the form of war, the form of crisis, um to build an evidence base, we need to conduct research even though the conditions are very, not very good. And that evidence is needed at individual level, at facility level, at national and at international level. And so prices bring opportunity for scientific and clinical breakthrough. Same as the media war brought, you know, huge advances in surgery. So, you know, we think that the similar advances in in mental health research are also something that, you know, prices can, can break and that's how, that's one way which they, um can be looked at. So this is a picture of us when, um, it was just before the crisis. So it was post COVID or kind of during the left over COVID, um, the end of 2021 but before the Russian invasion. And that's me and, uh, some of our team members in the brain. Um, and, um, so, um, we have been doing working with brain at the intersection of HIV, aging, um drug addiction and um uh mental health disorders. And we have currently um a list of three projects uh going on there. So, one project is uh what we call breast, which is APR I Optimal Support for treatments, a project which is a randomized medical trial to look at uh peer navigation system um for out of care, older people with HIV, um doing them to care. And then we added a component to that project to understand um how older people with HIV, quote during the war and how their providers, healthcare providers smoke during the war. And then we have another project called, which is Pursuing Optimal Results over aging. We decision made um which is um um building of a decision aid, whether or not to be small um HIV diagnosis um to um to an important person who wants life. So, um those projects were conceived before the war, but they were considered kind of like while COVID was already there. And so we sort of incorporated a little bit of the crisis mold into these projects, but we have to kind of like go a lot further into that um direction. So up to date. So currently has um um has been almost completed in terms of data collection. So we included 94 participants in TS um who are older adults living with HIV. Some of them were um previously diagnosed with HIV. So these are, um, I believe 57 participants that were previously registered. So that means that they had their hp diagnosis for a long time. They just were here and then there were 37 new participants who were newly diagnosed with HIV. So we had pretty much all of our follow up interviews done and um, those people were randomized into divorce. Um, 2 to 1. So about 62 participants had, um received um pr navigation um by somebody who's also an older adult living with HIV, which was successful in managing their HIV. And um 31 were controlled. And uh, those pr navigators were very interesting that I will share with you a little bit like what we did about that and that was very difficult thing for us to um, to assemble. Um, so we have some nr in the study, six participant study, which is not unusual in this population and uh the causes of death as far as we know were AIDS, um pneumonia oncology. And acute heart failure or cirrhosis. And in one case was an unknown cause of death. So something that I wanted to share is that, you know, we do get asked a more like how can you do work in your brain when? Well, first of all, like physically, you are yourself not in your brain right now. And also people who are in your brain right now, like how mobile they are and what, what's possible, what's the extent possible? So basically, we of course, have to do on the um social capital account we accumulated before um that acute phase of the crisis because we have built a lot of networks with our research assistants, with our clinicians and um with the peers, we established the community working group that helps divide our study and these people are presently in the field. So they're able to do the work and we are able to communicate with them virtually. And um the um um the recruitment of the Pr Navigators for our um project was a very um difficult but also a very interesting process because we have to um go by word of mouth, by referrals and recruit people by themselves patients and who would like to work with us to help other people like themselves. And so um they also have to be um themselves rather stable in terms of their treatment and access to treatment. And um we were, it was a fashion goal because it was really difficult to find these kinds of people. And when we were just starting that kind of project, it was really hard. But um I think that what helped us a lot were just a few things that I'm going to share. So, um first of all, um we had a very good relationship with the local clinical team and they had access to the electronic database from which they could draw the uh people's names. And then we also um thought about what would be the adequate compensation. So during the price, people particularly need income and very often they don't have it. So even a little bit that we could offer went a long way. And so the study coordinator was in touch with our participants, was able to explain all of that to the possible candidates. So they just were given the list and they started calling people and they explained what we were doing. And so, you know, by the, by um they were a few candidates and then, you know, there were a few conversations and then six people were recruited. So this is the goal. Um And um the person um yes, on the far left. So that's with my colleague. Um she's a researcher in the brain and the medical doctor by background and all the other people are um pr navigators in the middle and then the um people in left um on the far right is um who is um our um consultant. So she is the coordinator and supervisor for um the ne so the training was done face to face with some elements of virtual participation. And that was also important because all of our peer navigators were not able to be collected at the same place. Because at the time when we were recruiting them, quite a lot of people in Ukraine were internally displaced and some were already refugees. And so our peer Navigators were also in the process of uh coming and going. So some two of them actually were not in Kiev at the time. So we left the city and then we came back. And so we did not decide, we decided not to make that ri but rather just, you know, take all those um things as they came. And um so that element of flexibility was what helped us and say, I think the study because we were able to adopt um just, you know, to, to what was happening and um um and create the community and the sense of unity among these people. So what we learned is that um the capacity for a clear person to take one beneficiaries for patients like themselves is maximum seven people. So more is just impossible. And then um the most important resource that PM Navigators wanted was the consultation with a psychologist for motion high G for their own mental health. And for um briefing about the kinds of problems and the kinds of questions and concerns that their beneficiaries were sharing with them, but not so much the HIV clinician. So we knew the basics of HIV and these questions rarely came about. So we found that over seven months, um our psychology supervisor back to 10 group consultations and approximately 30 individual consultations for each Pr Navigator. And the key concern was the boundary setting with beneficiaries because people had so many issues they wanted to share with their Pr Navigator that it was very difficult for the Pr Navigator to say no, but they have to at some point. So our um intent was to make it um accessible to people and to have a hybrid version to adapting both to Pr Negator wishes and to their beneficiaries also in person group discussion was very important. And that was creating both um a sense of community of practice of P Navigators. But also it was helping our um uh Pr Navigators to have a sense of joy in, in all that blood work and getting together was a rescue for them. So we believe that um you know, it's important to kind of like once you recruit people to retain them. And so we are currently using our Pr Navigator team as experts by experiencing co production of the para decision for our next study. So these are insights from the group work that uh was organized and you can see that there, there is a computer there And so there are some people who are joining online and that's the office in Kiev where, uh, Pr Navigators and the consultant and study coordinator were coming. And then we did a little bit of like merchandise, like, you know, with, um, the Cops, with the name of our project that we gave them for Christmas, just like little things like that just for, you know, for, again, increasing that sense of joy, but also um a sense of unity. So then um let me just give you a little bit of sort of the context of where these people have been working. And uh we put that from a longitudinal survey of uh older people with HIV that we did during the war, we started that during COVID and then we continued. So we um um we included uh 44, it was 123 older people with HIV. Uh about half of them were female. And then we started them four times about six months between um the surveys and the last time was um in summer 2023. So they were recruited from the TFA Center and the T treatment clinic. So that means that half of them had an eviction as diagnosed. So that recruitment was enabled by both word of mouth and the relationship with clinicians. The interviewers were psychologists who were no one trusted by patients. Um And participants compensation was done virtually. So that's the demographics for our sample and you can see that quite a lot of them were employed um full time even um them were um having um a comorbid addiction and also quite a lot of them have another health condition. So what I found wasn't quite unexpected, we found that older women with HIV had poor mental health than older men. And that was true for depression, depressive symptoms, anxiety symptoms, and also the um uh the success quality life. And um so what was significantly connected to mental health was age, gender. Um Employment data, substance use use for social support once you would control for that, um substance use continues to have an impact on mental health out. So people with substance use have poor mental health generally. Um However, what is very interesting to us is that people with substance use have higher self reported resilience scores and that kind of goes back to the question where, you know, what doesn't kill, you can make you stronger. And that is what we saw in that population of older adults with HIV in Ukraine during the war. So those who had substance use on top of that for doing better in terms of self reported resilience. The question of course is for how long that better can hold? Would that at some point, you know, disappear as the crisis continues um or would it continue for, you know, indefinitely? Clearly, nothing goes on forever. So that's an open ended question. So just to summarize. And um you know, what I want to kind of um highlight here is that we learned some insights from this formative work during the war. So some things that concern um patients is that negative impact on mental health are like huge um chronic conditions of care are compromised and that is very true. Um however, people who are, who have been experiencing a lot of trouble in their life and those who are considered to be very vulnerable actually have a lot of resilience. And so certain lessons can be learned from them. And um at the same time, they can also be um it, it cannot be like the the negative impact of mental health can be um or more. But also we want to find something that puts providers themselves. So even though it wasn't the focus for our study just yet, we learned that um resilience at the systemic level is something that cannot be taken for granted because individuals have limits. And so to what extent the mental health providers themselves is affected, it's an empirical question. We don't know, no study has ever been done on that. But also, I totally observed that junior clinicians such as nurses and frontline workers, healthcare workers are very likely to be possibly more effective because um they are likely to be female, they are likely to be less paid. They are also very often internally displaced or become refugees. And so there needs to be a consideration for some programs to support those healthcare workforce. Um because otherwise they wouldn't be positively able to impact patients. I have a whole bunch of other slides, but I will leave you with that because I think that you have had enough of me and um I hardly have time from public. Thank you so much and I would be happy to, it is possible for inviting me here to, to present my uh lessons learned from my research experience. Uh My name is Alexander, I'm a research assistant at college Children and at the University of Islam for the past couple of years, I've been fortunate enough to be working closely with doctor on a few projects including Cross. If we mentioned that to give you a brief induction by myself, I am interested in exploring ca appropriate acceptable and physical approaches to strengthening consistence far settings and I be focusing and that we will be expressed and from a sociological uh angle. Uh I'm also interested in psychos psych, a passion that I discovered and I developed at the institute for connected communities at the University of East London, working closely with Professor G Dia and Professor Mary. Um I used to think that being a researcher is somewhat less valuable and the goal is to become a fully dependent researcher. However, in my journey, I've been fortunate enough to be working closely with amazing things that uh transitioning between departments and making close disciplinary connections. I learned that being a early career researcher is probably one of the best stages to be at, especially whenever you have flexibility, support, and great mentorship. Uh Just before I dive into the lessons that I learned, I just want to give you a brief overview of what I mean. When I say global mental health, I was here that the issue of global mental health, but essentially it focuses on the same priority areas as uh public health. But with regards to, to mental health. And I'm sure some of you have already seen that image here. I took it from uh linkedin. I think it's been shared by, by your school of public health folks. Uh I added a few focus areas including cyber psychology and also I added that stuff in green so I can find state that I put in public health. Uh But however, what I want to emphasize here is the interdisciplinarity of, of uh di of dimensions and also the the evolving nature of government health that focuses on bridge the healthcare treatment gap for all and other old circumstances. Uh Just to give you a brief uh overview of the projects that they are ongoing in Ukraine. Uh Julia mentioned cross uh so during the COVID-19 and during the pandemic, our team has continued to adopt the peer navigation uh uh strategy focusing on all the people who live with HIV in Ukraine, especially those who are out of care uh and enabling them to, to take inform decisions regarding disclosure of their HIV status and engagement uh with care. But during this time, we also engaged with uh addiction and uh HIV providers in Ukraine. And we observed that while some clinics have lost their staff during the crisis, uh others implemented innovative uh strategies to boost their staff, wellbeing and mental health. Um For the past couple of years, we conducted uh various uh activities to impact the healthcare semi serious, the the impact of of war and crisis on on the mental health of workers. We in May 2022 we conducted uh an expert panel and I'm proud to say the professor. So and Rosano, our were on that panel uh from that from those lessons we went on and uh had open discussions with uh with experts on the ground in Ukraine and I'll talk about the lessons that I learned. So the first lesson uh is that one conflict is ongoing in, in eastern Europe and you know, in, in other settings, I learned that crisis like uh price like settings are not necessarily specific to a setting. Uh So in discussions with colleagues from, from the UK, from Ukraine uh and, and the USI learned that even in high income countries, there are places where um they, they kind of resemble price tenting. So they have uh increased poverty, they have scars resources and they love uh trained healthcare providers Um II also drawn some parallels that can be kind of simulated between Ukraine or crisis settings and high-income uh countries. For example, in uh in Ukraine, we learned that financial incentives do work for the short term. So to motivate staff and to, to boost staff retention and uh motivation crisis. However, in the long term, we learned that cle uh uh social factors and community resilience are, are vital. So similar to the NHS mental health and wellbeing helps. They were set up in 2021. Uh We learned that some clinics in Ukraine actually implemented similar approaches. Uh So they were providing the, the staff with access to mental health support and uh wellbeing uh support as well. So this leads me to the second question and Julia kindly mentioned on, on that earlier that healthy resilience during price comes at a high human cost. And we learned that during the COVID that uh increased workload, burnout, uh poor working conditions and other factors are associated with uh or impacting job satisfaction. Um In Ukraine, we, we learned that they, they initially presented untradable resilience during the COVID-19 and then during the war. However, as the country continues, they may experience uh increased adverse psychosomatic uh symptoms such as burnout, depression or anxiety. Uh And I put here quotation in, in the words of that, one of our main collaborators in in Ukraine and one of my inventors uh clinicians are there to help everyone in need. But the main unrecognized challenge right now is clinicians own mental health. Indeed, workers need more than a close. It is argued by your general director in 2023. So the questions that can uh who can help from line clinicians with recent times of crisis and what can be done to support healthcare resilience during and post crisis. So firstly, II would say that governments donors, local and international NGO S uh play a key uh part in directing resources and accounting for contextual masses and contextual needs including local needs. Um However, I would like to draw some of my early experience while I was a student and when I can followed the Global Me Health Monitor and coalition. So that was shortly after the Russian invasion of Ukraine in 2022 I was initially frustrated with a little help that I could provide and I always keep asking uh around friends, peer col colleagues, lecturers on the best way to actually get involved even though uh II was here in the UK and the country was taking place in uh in Ukraine. Um And I learned that trainees like medical students, um students, nursing, social workers, students in clinical psychology can help Ukraine or can help clinicians in Ukraine and clinicians in other price settings by offering uh you know, remote counseling sessions by by raising awareness of underground issues, by co producing outputs by mentoring others and by building strong partnerships. Um Both students and, and practitioners, as many countries can come together and uh produce uh brochures on for psychological aid or, you know, those with the clinical background can uh provide, as I mentioned, remote basic counseling uh services. But I think it's very important to take a step back and reflect on, on the context and culture. And I want to emphasize on the role of engaging with local communities understanding their priorities and, and the best way to do that is to actually ask the local providers or, or local target population in our case, will be local providers. Uh What are the their needs, what, what the resources are and how it's best to, to actually engage with them. A few weeks ago, we organized uh a panel on uh conducting health research in humanitarian settings. Uh Sorry. And uh one of our colleagues and, and partners mentioned that uh during the, the conflict in uh in Crimea in 2014, they had to adapt the research methods and the way they did that was by having direct consultations with uh with uh local communities. So, so in a sense, II would say that en engaging with local communities is the best way to actually even conceptualize a research pro project or uh uh intervention to, to build sustainable health systems. Uh I can put it here to our hope for you. If you wanna check this out, this is freely available on youtube. And uh yeah, you can always go back to that. Um So that is me and I have brought up uh to my second point. And that is that whenever you design a health research project, you have to engage with local communities from early stages, even before you have, you know, the, the the final outcome in mind. So you have to, to engage with that to ensure that you, you conduct the research in a respectful and ethical manner. So I will try to, to wrap up my, my talk with uh a call for, for operative endeavors. And it is well known that there will never be enough psychiatrists, psychologists or other specialists in mental health to provide services for the wide range of, of problems under the rubric of mental health. Uh So as as we navigate research and practice in in global health IV to, to promote the power of uh cultural diversity and to support those whose voices are solid, especially in shaping uh research and practice, raise awareness of, of mental health uh issues on the ground and increase access to the services. Um I will send you to hear, to call for those who are interested in uh in uh checking out the, the master in global mental health. And if I'm not mistaken, there will soon be available some courses uh ned by the Center for Global Mental Health. Um Last but not least, I would like to thank my, my colleagues and my mentors. Uh who supported me and guided me in uh in my journey to mental health, re global mental health research. And I'm particularly grateful to doctor I know that Professor Julia said, and professor, she actually for, for guiding me and being the the best mentors II could ask for. Um I've been really here some of the projects you already seen that uh some of images, you already seen that image. And uh these are just two of our, of our white uh white team colleagues. Um I've also include some red, but I'm more than happy to share the power in a few minutes. Uh And thank you, thank you so much for your time. It's a wonderful presentations. Thank you. Um um I'm Dennis, I'm a child psychiatrist, but uh thank you for being the one who talks about Nicole. And um this is Mark, uh it's called um the Ukrainian family. It was uh done in 1942. It down, I think yesterday, in fact, c easily uh you week Ukraine is uh most of, you know, have been very badly affected by the rule and especially in terms of displacement of people. So 6.2 people have left Ukraine. It's a huge number. Many uh ended up in, in the UK. This is a picture I took um um I think it was Saturday. So it happened Thursday. This was Saturday in which is a city um on the border of Ukraine and Russia, uh in Poland. And this is a 13 year old boy from a place called, uh, his sisters looking at him, uh, what they should do. It's very interesting, um, picture about how families get this structure in your brain. Um, this is a, uh, uh, you go with her with a cat as well. You can see that, um, she seems quite happy and the cat seems pretty stressed. So it's not just about, um about human beings but also pose some animal and you can see, but this little boy here has brought a strock in, in that. So, you know, um, uh rats um that he brought from, from Ukraine to follow as well. Um The, um, so essentially you have lots of Children. Uh, some of most of them I think as, as you mentioned before, uh, seem remarkably resilient to me. I, I've spoken to 100s, maybe even thousands of kids from Ukraine and most of them seem to be remarkably unaffected by, by the war. Uh, which is something I wouldn't really typically expect. Some, the ones that, uh are in the UK. There is a minority of Children who are significantly affected, very badly affected by what happened to them and you need to be really thinking about them as well as all other kids from all other uh rule zones. But that's uh around in the UK. Uh We do some really cool things with kids. Uh uh Basically for most of you are familiar with how um trauma work goes. Um um Children who are affected by any kind of trauma, which very often have this reexperience some of these events. So most people will know about flashbacks and other types of experience and which could happen in any modality and hyperarousal and avoidance. And the the key to treatment for these Children is to reestablish a coherent story that they can tell without being scanned or they had. And the way you can do this, you can do it many different ways. One way is to process what happened by deri of depicting or tell them about what happened. And this is one way to do this is um by creating t-shirts. I actually have one of those, they might be very proud of it and you can see that very often Children would um uh have from what happened to them. This little boy is from one of the eastern cities and he spent two weeks uh in an environment um which looked a bit like this of a of a massive Soviet uh time when he arrive, he was really very badly affected by what happened to him. Uh His tshirt was basically what he saw for two weeks in Ukraine. And then very, he put the underground sign there and it says underground in Ukraine, I thought it was really what happened to her. Um I would just uh be be mindful of the time I would just say that. Um but essentially what you all come across Children who have strong and still strong. Uh You think it is just one example of uh of these Children? Let me see the Children. Uh I think they will be just a couple of things to give to remember. Uh what we have is that um I uh people who work with kids have these two like opposite ideas about what should be down to these kids. So one school is like, that's not what, what would happen, but it will be by itself that you put out. And the other, the degree that it's good for them to talk about them. And we have to take these ideas of good. So every child who went through trauma have a time when they went to see about the same and when that happens, it's really super important to allow them to talk about what happened, allow them to ask questions about different answers. Um I have um and I want to begin to build this for what happened, how they came from this difficult situation to the relative safety of the UK. That's number one, number two is one of the patterns of these charts. I it's the stimulated the scientist, um a new city, new country and they get new friends language and this and, and it's actually so and, and before you sleep and the, the, the key message to the parents of these cases. Is that what you, what you had is especially in the past few weeks moving to, to be it's routine one thing. So, um what to do now? Uh and uh wow, scarry. No prayer is the religions and, you know, I tell a story and then speak and that sort of routine predictability is the number one thing. So uh just sometimes that uh loads of kids around, most of them will be fine, It will be very badly. It needs to be able to be given study. Whatever you can allow me to do is is by listening to them answer any questions and uh making sure that they have the right thing in their life. Thank you too. It um and we have got a question coming online. Um It's um what immediate intervention or specialist resources or tools that you find useful and available that you can offer to healthcare providers um on dealing with mental health, mental health in crisis. You want, you want to come up just in case you feel things. That's a good question here. So the abbreviation of CBT would be the most with you like 10 years ago. Nobody knew what it stands but not everybody knows what stands coming through behavioral therapy. And so there is a variation of it called TF CBT, which is Trop TBT. And that's what most people would benefit from. There are many, many, many other psychological therapies. But if you want to remember one from today. It's TF CBT. Some of us respond to behavior therapy. You can deliver that individually to the child and the family and in the groups of this, uh there is uh if, if you are really curious um to learn more about this project than uh Google this thing, go to foundation and then you can book yourself for a two day training on delivering these groups of TF CBT for, for Children. Um There are a lot of fun to do. I've done lots and lots of kids, love them, parents, love them. They have the time to the e of the groups is you do psycho education of what it actually is that your child experiences in the family and give Children skills and have to overcome experiencing. That's the mm Thank you uh very much for this question. So because I'm not a um provider of mental health services, I would not name a specific therapy, but I would say what uh was emphasized by our research participants and also what the experience and found. So people need breast from the hard work and daily pressures and usually um during the process and during the work, what we found is that this was stretched first. So things like sometimes like this one where you can visit and um for work purpose, you know, be together but have a good time, be able to chat, be able to have a cup of tea with four weeks, you know, even like dress up a little bit and uh be, you know, talking about the experience together. So that feeling of community um is very often not there because there are no resources for that. But sometimes we don't even think about the importance. So I found through the um conversations with our participants that, that is the most needed thing and it needs to be done in person if possible. So online doesn't quite cut it because it doesn't give people just a break from very, you know, intense pressure. And also the more time you are in this stress mode, the more you need it. But the less often you can do that because there is no time or resources, nobody can, you know, shoulder the burden while you are away at the appointment. If for example, the hospital has lost, you know, quite a step. So how to do that is a difficult question to answer. We try to incorporate elements of that into our process by just, you know, for even like the members of our research team and our uh affi to do something like that. And we find that people find um some, some new sense of purpose through that, even sharing, you know, a conversation, it doesn't have to be even about difficult things, can be about anything, anything at all, but just being together physically and you know, smiling at each other and even laughing and like all these kinds of everyday things. They go a very long way and they also build the community of practice, which is, you know, based on the. So it's uh the theory of social capital and the theory of social inclusion where, you know, you feel not alone, you feel less stigmatized, you feel normal in the best sense of this word. And that's so, so fundamentally important. You know, it's, it's exactly why conferences like that are important, but it's also why things like that are important in price settings. So, you know, I also urge all of us to do more of that if we can, you know, like bring people in from those settings so that they can come and visit um or somewhere safe where, you know, it's nearby but they can um uh you know, access that uh and just uh give people a little bit of a break because, you know, prices are going on for a long time and we probably will continue roll. So we can't wait until the crisis is over to, to, to start helping people right now. II just can tell people, I know the past couple of years is uh not having open discussions with uh providers and asking them what are the meaningful and not the other of the and what, what they call meaningful in terms of, you know, their wellbeing. Uh I also learned that, you know, those uh clinics who provide support to them as I mentioned earlier in that. So, yeah, one a as you mentioned, we are not still uh the, we will start going on the health and the health. Thank you so much. Um That's the end of the session. It is time for lunch, but I just want to thank all three speakers for navigating the one session.